Free BLOOD_EXPOSURE_51467 - Indiana

Notification of Blood or Body Fluid Exposure - Page 1 of 3
Emergency Medical Services Provider
63660

Indiana State Department of Health State Form 51467 (9-03)

This form is to be completed by the exposed Emergency Medical Services Provider in compliance with IC 16-41-10-2.

DIRECTIONS - PLEASE READ BEFORE YOU BEGIN: 3 Fill-in circles like this: 1 Print firmly and neatly. Not like this: 2 Only use pens with blue or black ink. Mark mistakes like this:

4 Print capital letters only and numbers completely inside boxes: A 2 C 3 5 Please complete all items on form.

6 Date format:
MM/DD/YY or MM/DD/YYYY

7 Time format:
HHMM - 24 hour clock

SECTION 1: Information Regarding Emergency Medical Services Provider Exposed to Blood or Body Fluid

Last Name

First Name

MI

Telephone Number

-

-

Number & Street Address

City

State

Zip Code

Sex: Male Female

County

Date of Birth

/

/

E-mail Address

Race (fill in the circle(s) that apply):

American Indian or Alaska Native Native Hawaiian or Other Pacific Islander

Asian White

Black or African American

Ethnicity: Hispanic or Latino Non-Hispanic

Employer

Address of Employer

City

State

Zip Code

-

Telephone Number

-

-

Fax Number

-

-

E-mail Address

SECTION 2: Exposure Information

Run Number (if applicable):

Date

/
Other

/

Time

Location (fill in the circle that applies): Incident Site Ambulance Emergency Department

If Other, specify:

THIS FORM CONTAINS CONFIDENTIAL INFORMATION PER IC 16-41-10-5

Notification of Blood or Body Fluid Exposure - Page 2 of 3
Emergency Medical Services Provider
63660

Indiana State Department of Health State Form 51467 (9-03) SECTION 2: Exposure Information (Continued)

Person(s) whose blood or body fluid you were exposed to:

Name

Date of birth

/ /

/
Unknown

Name

Date of birth

/
Unknown Other

(add additional names on a separate sheet if necessary) Fill in the circle(s) to indicate which fluid you were exposed to: Blood Saliva Semen Vaginal secretions

Unable to identify body fluid

If Other, specify

Fill in the circle(s) that describe how the exposure occurred: Skin broken with a contaminated needle or object Eye, mouth, or other mucous membrane exposure Non-intact skin exposure Other, specify:

Comments and other pertinent information

SECTION 3: Submitting Completed Form The Emergency Medical Services Provider must submit a copy of this report to each of the following: 1. Employer's Medical Director (must be notified within 24 hours of exposure)

Name of Medical Director

Address

City

State

Zip Code

-

Date:

/

/

Time

THIS FORM CONTAINS CONFIDENTIAL INFORMATION PER IC 16-41-10-5

Notification of Blood or Body Fluid Exposure - Page 3 of 3
Emergency Medical Services Provider
63660

Indiana State Department of Health State Form 51467 (9-03) SECTION 3: Submitting Completed Form (Continued)

2. Emergency Department's Medical Director:

Name of Medical Director

Name of Medical Facility

Address

City

State

Zip Code

-

Date

/

/

Time

3. Indiana State Department of Health 2 North Meridian Street, 5K Indianapolis, IN 46204 FAX: 317-233-9271

Date

/

/
SECTION 4: Exposure Follow-up Notification

Fill in the circle next to the physician you want to receive the results of the testing done in accordance with 16-41-10. The physician of your choice must inform you of the results of testing within 48 hours of receiving the results.

Exposed Emergency Medical Services Provider's Physician

Name

Address

City

State

Zip Code

-

Telephone Number

-

-

Fax Number

-

-

Employer's Medical Director (named on Page 2).
SECTION 5: Signature and Date

Signature of exposed Emergency Medical Services Provider

Date

/

/

THIS FORM CONTAINS CONFIDENTIAL INFORMATION PER IC 16-41-10-5